How is it that something we have been practicing for years suddenly gets harder? That something we knew how to do before we were even born becomes a challenge after cancer?
Studies have shown that between 30% and 50% of all cancer patients have significant sleep issues, and as many as 95% of us complain of problems sleeping at some point in the process of diagnosis, treatment, recovery and survivorship. Falling asleep, staying asleep, achieving deep, restful sleep and feeling refreshed after sleeping, can all become challenging. That elusive rest we all need so badly gets interrupted by stress, illness, age, and excessive (blue) light. We’ve all heard about the problem and experienced the impact on our lives, but what can be done about it? And what is the interplay between cancer and sleep?
So many aspects of cancer interfere with our ability to sleep, starting with the anxiety of diagnosis. Worrying about the impact of cancer on our lives and the lives of those we love can make it difficult to fall and stay asleep. While it is normal to go in and out of deep sleep throughout the night, when we are in a light-sleep phase, unpleasant thoughts can find their way in, making it harder to fall back into the restful sleep we need. A quick trip to the bathroom becomes an hours-long interruption as anxiety grabs at our drowsy minds. And during semi-conscious states, the rational part of the brain is less active, the emotional part more active, so the fear takes control. Anxiety and depression can seem like they run the show.
Cancer Causes Sleep Disturbances
The stress of dealing with cancer can also make it hard to maintain our normal sleep schedule. Stress leads to the release of adrenalin—that powerful hormone that helps us find the energy to evade danger—which in turn can throw off the release of cortisol, another hormone which helps control our sleep/wake patterns. Hormonal changes as a result of surgery (removal of hormone producing organs) or other treatment (hormone suppressants or even steroids as part of treatment), can also interfere with our normal sleep cycle, keeping us wakeful when we would normally be sleepy.
Side effects of treatment also can contribute to sleep disruptions. Intestinal distress can keep us awake or cause us to wake more frequently than usual. Pain can interfere with sleep, and pain meds can throw off normal sleep cycles, keeping us zombie-like but not fully rested. Even lack of exercise during treatment and recovery can influence the natural sleep drive and interfere with healthy sleep patterns. Fatigue, a frequent side effect of cancer and its treatment, compels us to nap during the day, further disrupting sleep cycles, and the spiral continues.
Sleep Disturbances Influence Immune Health
While the occasional lack of a good night’s sleep might feel like an inconvenience, persistent sleep problems are more than that, leading to chronic fatigue, suppressing the immune system, influencing insulin and weight management, affecting blood pressure and heart health, limiting our cognitive abilities and contributing to emotional volatility. It’s not just that we are grumpy because we didn’t get a good night’s sleep, but that lack of sleep and break with normal sleep habits makes it harder to fight the cancer that started it all. In fact, studies have shown that even moderate decreases in nightly sleep can increase the release of pro-inflammatory cytokines (read more about those here,) leading to immunodeficiency and general health issues.
In addition, recent research suggests that our natural supply of melatonin is an antioxidant that helps fight cancer by stopping the growth of cancer cells. But when we stressfully stare at screens late into the night the release of melatonin—which normally occurs shortly after nightfall and helps induce sleep—is suppressed, further weakening the immune system. There even seems to be a correlation between night shift work, which requires a sleep/wake cycle in conflict with natural circadian rhythms, and increased incidence of some types of cancer.
Proactive Inaction
Although forces seem stacked against us, there are things we can do throughout the day and at bedtime to encourage better sleep and establish habits that support a healthy immune system.
It starts with maintaining a regular sleep schedule. Try to go to bed and wake up at the same time every day, even on weekends. This helps set the circadian clock that will drive your cortisol cycle, the release of melatonin, and the pattern of deep and restful sleep that helps you feel refreshed. It is not always possible to maintain a schedule, but it’s a goal to work towards. Also, try to incorporate exercise into your daily routine. Even 20 to 30 minutes of walking has been shown to promote healthy sleep, so long as it is completed at least four hours before bedtime.
Caffeine and alcohol also influence how alert or sleepy we feel, and how well we rest when we sleep. A cup of coffee or tea first thing in the morning can signal that it’s time to be wake up and the caffeine binds with neurotransmitters in the brain that promote alertness. But caffeine too late in the day can make falling—and staying—asleep a challenge. Since our bodies vary, some of us can get away with an espresso after dinner, but for most of us, its best to stop ingesting caffeine by mid-afternoon. And while a cocktail or glass of wine might seem like a good way to unwind, alcohol is a stimulant and can interfere with deep sleep as well, so be thoughtful in your consumption. (There is also increasing evidence that alcohol is carcinogenic.)
Bedtime Story
As the evening comes to a close, it can be helpful to initiate relaxation practices, including yoga, self-massage, a warm bath, even reading a book. Just as we encourage young children to transition from their day of active play into restful sleep with a bedtime story and a quiet snuggle, it can be helpful as adults to establish a calming ritual that signals the body and relaxes the mind. That should include keeping screens out of the bedroom and ensuring the room is cool, dark and quiet—not always easy in our modern environment.
And if you climb into bed at the prescribe hour with every expectation of sleeping only to find your mind racing and your body tingling, try some deep breathing or meditation or listening to music to help you relax. But after 30 minutes or so, if it’s not happening, get up and read or try something else that you find relaxing, so long as it doesn’t involve bright lights.
If you still can’t sleep after establishing good sleep habits, talk to your doctor about taking melatonin, valerian and other herbal sleep aids. Some herbal remedies can interfere with cancer treatment and shouldn’t be started without first checking. Your doctor can also refer you to palliative care resources at your treatment center, including Cognitive Behavioral Therapy (CBT) for sleep, and even prescription medications, which can help you get to and stay asleep, but don’t always allow your body to experience the natural sleep rhythms that ensure a truly restful sleep.
To Nap or Not to Nap
It often seems impossible to get through the day without napping, even when not in active treatment. The drive for sleep builds over the course of the day, increasing the need to sleep with each waking moment. We stave off some of that with caffeine, sunlight and activity, but sitting for too long, or a glucose spike and subsequent drop from a meal or snack with more simple carbs than fiber, and just the extreme fatigue of cancer and its treatment can make napping inevitable. So how do you practice safe napping?
Research suggests that for healthy individuals, a 10-minute nap is most effective for feeling refreshed and sharp. Too long, and it takes a while to break free of the cobwebs. Too short, and there’s no real benefit. But for someone in the middle of cancer treatment, that may not be sufficient, especially if nighttime sleep is interrupted or unrestful. Unfortunately, daytime napping can interfere with quality nighttime sleep, making a nap the next day all the more essential. Establishing good sleep habits helps minimize the need for napping thus avoiding a downward spiral of sleep degradation. But if you need a nap, take it. Then, think through your day and see if there was anything you could have done differently to foster better sleep habits. Perhaps a walk when mid-afternoon sluggishness hits? A bedtime journaling practice to release the days worries and prepare you for sleep?
It’s easy to overlook the contribution sleep makes to our physical and emotional health, as well as how our daily activities can influence the quality and quantity of sleep we get. Incorporating a few new habits into your daily regimen might help ensure you get the rest you need to cope with cancer and be your best self.
Learn more about sleep and the brain.